Adult Health II: Cardiovascular and Respiratory (NUR 440 B)

The correct answer is: fluid restriction and diuretics as necessary.

Explanation:

In Acute Respiratory Distress Syndrome (ARDS), maintaining fluid balance is crucial due to the risk of pulmonary edema, which can exacerbate respiratory failure. Managing fluids carefully can help prevent further complications and improve oxygenation. Fluid management in ARDS is focused on avoiding fluid overload while still maintaining adequate perfusion to vital organs. Fluid restriction helps prevent the accumulation of excessive fluid in the lungs, which can worsen pulmonary edema and impair gas exchange. Diuretics (such as furosemide) may be used to remove excess fluid if the patient is retaining too much, further helping to manage pulmonary edema and reduce the work of breathing. These strategies help keep the lungs as dry as possible while ensuring that systemic circulation is not compromised.

Why the Other Options are Incorrect:

hydration using colloids.

Colloids are a type of intravenous fluid that can draw fluid into the bloodstream, but they are typically not used in ARDS to maintain fluid balance. In ARDS, the primary goal is to prevent further fluid accumulation in the lungs, and colloids could worsen pulmonary edema. Crystalloids (like saline or Ringer’s lactate) are used more often, but still with fluid restriction.

administration of surfactant.

Surfactant is a substance that helps reduce surface tension in the lungs, facilitating better lung expansion and gas exchange. While surfactant administration is used in neonates with respiratory distress syndrome, it is not a standard treatment for ARDS in adults. The main concern in ARDS is managing fluid overload and maintaining ventilation, rather than surfactant therapy.

keeping the hemoglobin at levels above 9 g/dL (90 g/L).

While it is important to maintain adequate hemoglobin levels for oxygen transport, keeping hemoglobin above 9 g/dL is not a specific target for managing ARDS. The focus is more on optimizing oxygenation, managing ventilation, and preventing fluid overload rather than setting specific hemoglobin targets unless anemia is contributing to poor oxygenation.

Summary:

In ARDS, maintaining fluid balance is key to preventing further pulmonary edema. This is best achieved through fluid restriction and the use of diuretics if needed. The other interventions, like colloids or surfactant, are not appropriate for ARDS management in adults. Hemoglobin levels are monitored but are not the central focus in managing fluid balance for ARDS.

The correct answer is: Potassium level.

Explanation:

Furosemide (Lasix) is a loop diuretic that increases urine output, and it can lead to potassium loss. This is particularly important because digoxin (Lanoxin), a cardiac glycoside, has a narrow therapeutic range, and low potassium levels (hypokalemia) can increase the risk of digoxin toxicity. Low potassium levels can make the heart more sensitive to digoxin, potentially leading to serious cardiac arrhythmias or other toxic effects. Because the client is taking both furosemide and digoxin, the nurse should monitor the potassium level closely to prevent hypokalemia, which can enhance the effects of digoxin and increase the risk for toxicity.

Why the other options are less relevant:

Digoxin level: While it’s important to monitor digoxin levels to ensure they remain within the therapeutic range, it is more immediate to ensure that the client has adequate potassium levels, as low potassium is a common precipitant of digoxin toxicity. Once potassium is stabilized, monitoring the digoxin level may become more important if symptoms of toxicity are present.

Creatinine level: Furosemide is renally excreted, and kidney function is important to monitor, but potassium levels are more directly affected by furosemide use, and the main concern with digoxin toxicity is potassium imbalance.

Sodium level: While sodium levels are important to monitor, they are less directly related to the interaction between furosemide and digoxin. The primary concern in this scenario is potassium balance.

Summary:

The nurse should primarily review the potassium level in a client taking both furosemide (which can cause potassium depletion) and digoxin (which can become toxic in the presence of low potassium). Monitoring potassium helps prevent complications such as digoxin toxicity and cardiac arrhythmias.

The correct answer is: "The shunting caused by the PE increases the client's risk for atelectasis."

Explanation:

Pulmonary embolism (PE) is a blockage in one of the pulmonary arteries, usually caused by a blood clot. This blockage can cause various complications, including shunting of blood, which refers to blood flow being diverted away from the alveoli (air sacs in the lungs) where gas exchange takes place. In cases of PE, the shunting of blood to areas of the lung that are not ventilated (due to the embolism) can increase the risk of atelectasis. Atelectasis occurs when a portion of the lung collapses, usually due to a lack of ventilation or obstruction, leading to reduced surface area for gas exchange. In the case of PE, shunting reduces the perfusion of well-ventilated areas of the lung, while poorly ventilated areas (because of the blockage) still receive blood flow, increasing the risk of atelectasis.

Why the other options are incorrect:

"This client is not currently at risk for developing atelectasis.": This statement is incorrect because clients with pulmonary embolism are at risk for atelectasis due to the altered ventilation-perfusion (V/Q) mismatch and shunting caused by the PE, as explained above. A PE disrupts the normal lung function, making atelectasis more likely.

"This client is only at risk for atelectasis if pulmonary hypertension occurs.": While pulmonary hypertension can complicate a PE and potentially lead to right-sided heart failure, atelectasis can occur even without pulmonary hypertension. The shunting and impaired gas exchange from the PE itself can lead to atelectasis, independent of pulmonary hypertension.

"The dead space created by the PE increases the client's risk for atelectasis.": This statement is somewhat misleading. Dead space refers to areas of the lung that are ventilated but not perfused with blood, meaning gas exchange cannot occur in these areas. While dead space is a consequence of PE (as blocked pulmonary arteries create areas of the lung where ventilation cannot match perfusion), it is not directly responsible for atelectasis. The shunting and ventilation-perfusion mismatch due to the embolism are more directly linked to the risk of atelectasis.

Summary:

In clients with pulmonary embolism (PE), the shunting caused by the blockage of blood flow to certain parts of the lung increases the risk for atelectasis. The diversion of blood away from ventilated areas can impair oxygen exchange and promote lung collapse, leading to atelectasis.

The correct answer is: Pressures in the left ventricle and atrium are increased.

Explanation:

In left-sided heart failure, the left side of the heart is unable to pump blood efficiently to the rest of the body. As a result, blood backs up into the lungs and causes increased pressure in the left atrium and left ventricle. This increase in pressure is one of the key findings during cardiac catheterization in patients with left-sided heart failure. During cardiac catheterization, pressures are measured in different parts of the heart. In left-sided heart failure, the elevated pressure in the left atrium and left ventricle is due to the impaired ability of the left heart to pump blood effectively. This leads to congestion and fluid retention, particularly in the lungs, causing symptoms like pulmonary edema.

Why the other options are incorrect:

Pressures in the left ventricle and atrium are decreased: This is incorrect. In left-sided heart failure, the pressures in the left ventricle and atrium are increased, not decreased, because of the fluid backing up due to the heart's inability to pump effectively.

Pressures in the right ventricle and atrium are decreased: This is incorrect. While left-sided heart failure can eventually lead to right-sided heart failure (congestive heart failure), in the acute setting of left-sided heart failure, the right side of the heart typically doesn't have decreased pressure. The increased pressure from the left side can affect the right side, causing increased pressures in the right atrium and right ventricle over time.

Pressures in the right ventricle reflect functioning of all heart functioning: This is incorrect. The right ventricle pressures are important but primarily reflect the function of the right side of the heart and the pulmonary circulation. The left ventricle and atrium pressures are more directly impacted in left-sided heart failure.

Summary:

In left-sided heart failure, the nurse should expect to see documentation that pressures in the left ventricle and atrium are increased after cardiac catheterization. This reflects the typical hemodynamic changes caused by the inability of the left side of the heart to pump blood effectively.

The correct answer is: Increase FiO2 to 70% and increase PEEP to 8.

Explanation:

ABG Results Analysis:

pH 7.37: This is within the normal range of 7.35-7.45, so the pH is stable and not indicating severe acidosis or alkalosis.

PaO2 40: This is critically low, as normal PaO2 levels range from 75-100 mmHg. A PaO2 of 40 mmHg indicates severe hypoxemia, suggesting inadequate oxygenation.

CO2 45: This is slightly elevated (normal range is 35-45 mmHg), indicating a mild respiratory acidosis due to the inability to eliminate CO2 efficiently.

HCO3 24: This is within the normal range of 22-26 mEq/L, indicating that there has not been significant compensation by the kidneys yet.

Based on these results, the primary issue appears to be severe hypoxemia (low PaO2), and mild respiratory acidosis.

Ventilator Settings:

Assist Control (AC) mode: This mode provides full support, delivering a set tidal volume at a set rate but allows the patient to trigger additional breaths.

FiO2 50%: This is providing 50% oxygen, but given the critically low PaO2, increasing the FiO2 may be necessary.

PEEP 5: PEEP (positive end-expiratory pressure) helps keep alveoli open, but 5 cm H2O may not be sufficient to improve oxygenation in this case.

Why the correct answer is Increase FiO2 to 70% and increase PEEP to 8:

Increase FiO2 to 70%: Given the severe hypoxemia (PaO2 40), increasing the FiO2 will help improve oxygenation.

Increase PEEP to 8: Increasing PEEP helps improve oxygenation by preventing alveolar collapse at the end of exhalation, thus improving gas exchange.

Why the other options are wrong:

A change in the ventilator mode to CPAP: CPAP (Continuous Positive Airway Pressure) is typically used for spontaneously breathing patients to keep the airway open. Since this client is intubated and in respiratory failure, changing to CPAP would not provide the necessary ventilatory support and would likely worsen the situation.

A decrease in tidal volume to 200: Reducing tidal volume would decrease ventilation and could worsen hypercapnia (CO2 retention). This is not an appropriate response to the patient's current ventilator settings, especially when the problem is primarily hypoxemia (low PaO2), not CO2 retention.

Increase the respiratory rate to 18 and adjust FiO2 to 100%: While increasing the FiO2 to 100% might improve oxygenation, simply increasing the respiratory rate is not the primary solution here. The major concern is the severe hypoxemia, and increasing FiO2 to 100% might lead to oxygen toxicity. Therefore, increasing FiO2 to 70% and adjusting PEEP is a more balanced and appropriate intervention.

Summary:

The patient has severe hypoxemia (PaO2 40) and mild respiratory acidosis (CO2 45). The current ventilator settings, although supportive, need adjustments to improve oxygenation. The correct action is to increase FiO2 to 70% and PEEP to 8 to help improve oxygenation while maintaining appropriate ventilation. The other options either address issues that are not as critical or would potentially worsen the patient's condition.

The correct answer is: Altered mental status and dehydration

Explanation:

In elderly clients, pneumonia may present atypically. This population is at risk for non-specific symptoms or may show signs of systemic infection without the typical manifestations seen in younger patients. Elderly clients may experience altered mental status (such as confusion or delirium) as one of the first signs of infection, including pneumonia. This can occur even before classic respiratory symptoms such as fever or cough appear. Dehydration is also common in elderly patients, particularly if they are not able to take in enough fluids, which can compound the symptoms of infection. These non-specific symptoms may be the first indicator that an elderly client is developing pneumonia, making it critical to monitor for these changes.

Why the Other Options Are Incorrect:

Fever and chills

While fever and chills are typical signs of pneumonia, elderly clients may not show a significant fever response to infection. The immune system weakens with age, and some elderly patients may not exhibit a high fever even in the presence of severe infection. Therefore, fever and chills may not be the first signs of pneumonia in this population.

Hemoptysis and dyspnea

Hemoptysis (coughing up blood) and dyspnea (shortness of breath) are less common in the initial stages of pneumonia, especially in elderly patients. These symptoms are more indicative of severe pneumonia or complications such as lung abscesses, and they are typically seen later in the course of illness or in more serious forms of pneumonia.

 Pleuritic chest pain and cough

Pleuritic chest pain (sharp pain that worsens with breathing) and cough are common symptoms of pneumonia, but elderly patients may not always present with these symptoms, or they may have a less severe cough due to impaired immune responses and decreased lung capacity.

Summary:

In elderly clients, the first signs of pneumonia may be more subtle and include altered mental status and dehydration, which can be mistaken for other conditions. Unlike younger patients, elderly individuals may not present with classic symptoms such as fever, chills, or cough at the outset. Therefore, early recognition of non-specific symptoms is critical in managing pneumonia in this population.

The correct answer is:  Presence of coronary artery spasm.

Why this is correct:

Stable angina is a clinical manifestation of coronary artery disease (CAD), which occurs when there is reduced blood flow to the heart muscle due to partial blockage or narrowing of the coronary arteries. This is often caused by atherosclerosis (plaque buildup) or temporary coronary artery spasm. The pain or discomfort associated with stable angina is predictable, typically triggered by physical exertion or emotional stress, and relieved by rest or nitroglycerin. Coronary artery spasm can temporarily reduce blood flow, leading to angina symptoms, even in the absence of significant atherosclerosis. Therefore, the presence of coronary artery spasm is a key feature of stable angina.

Why the other options are incorrect:

Associated with pulmonary disease:

This is incorrect because stable angina is a cardiac condition related to reduced blood flow to the heart, not a pulmonary (lung) condition. Pulmonary diseases, such as chronic obstructive pulmonary disease (COPD) or pulmonary hypertension, affect the lungs and respiratory system, not the coronary arteries.

Presence of a myocardial infarction:

This is incorrect because stable angina does not indicate an active myocardial infarction (heart attack). A heart attack involves complete blockage of a coronary artery, leading to irreversible damage to the heart muscle. Stable angina, on the other hand, involves temporary and reversible ischemia (lack of oxygen) due to partial blockage or spasm, without permanent damage.

Associated with renal disease:

This is incorrect because renal (kidney) disease is not directly related to the pathophysiology of stable angina. While renal disease can contribute to cardiovascular risk factors (e.g., hypertension, atherosclerosis), it is not a direct cause or indicator of stable angina.

Summary:

Stable angina is a condition characterized by predictable chest pain or discomfort due to reduced blood flow to the heart muscle, typically caused by coronary artery spasm or narrowing from atherosclerosis. The correct answer highlights the underlying mechanism of stable angina. The other options are incorrect because they either refer to unrelated systems (pulmonary or renal) or a more severe condition (myocardial infarction) that is not indicated by stable angina. Understanding the pathophysiology of stable angina is crucial for proper nursing care, including patient education, symptom management, and prevention of complications.

The correct answer is:  Connect the client's ET tube to an ambu-bag and assist ventilations via ambu-bag.

Why this is correct:

Immediate Action Required: Equipment failure of the ventilator is a life-threatening emergency because the client is dependent on mechanical ventilation for oxygenation and ventilation. Delaying intervention could lead to hypoxia, respiratory arrest, or death. 

Ambu-Bag (Manual Resuscitator): Connecting the client’s endotracheal (ET) tube to an ambu-bag and manually assisting ventilations is the most appropriate immediate action. This ensures the client continues to receive oxygen and ventilation while the ventilator issue is addressed.

Nurse’s Role: The nurse is trained to use an ambu-bag and should take immediate action to stabilize the client before seeking additional help.

Why the other options are incorrect:

Continue to monitor:

Continuing to monitor is not appropriate in this situation. The client is at immediate risk of hypoxia and respiratory failure due to the ventilator malfunction. Immediate intervention is required.

Page the physician to order a new ventilator:

While the physician may need to be notified, this is not the immediate priority. The nurse must first ensure the client is oxygenated and ventilated using an ambu-bag before addressing the need for a new ventilator.

Ask respiratory therapy to come assess the client:

Respiratory therapy should be notified, but this is not the first action. The nurse must take immediate steps to manually ventilate the client using an ambu-bag to prevent hypoxia and respiratory compromise.

Summary:

The ventilator failure is a critical emergency that requires immediate intervention to prevent hypoxia and respiratory arrest. The most appropriate action is for the nurse to connect the client’s ET tube to an ambu-bag and manually assist ventilations. This ensures the client continues to receive oxygen and ventilation while the issue is resolved. Continuing to monitor, paging the physician, or waiting for respiratory therapy are inappropriate as first actions because they delay life-saving intervention. By taking immediate action, the nurse ensures the client’s safety and prevents further complications. Once the client is stabilized, the nurse can then notify the physician and respiratory therapy to address the ventilator malfunction.

The correct answer is: Administer oxygen via high flow mask.

Explanation:

The client is exhibiting signs of respiratory distress (dyspnea, tachypnea with respirations of 38/min, and hypoxia with SpO₂ of 92% on room air), and these findings suggest that the client is experiencing a respiratory compromise, possibly due to a pneumothorax or another serious injury affecting the lungs or pleura following the motor vehicle crash. The first priority is to ensure adequate oxygenation. In an emergency setting, especially when oxygenation is compromised, it is critical to provide supplemental oxygen to the client to maintain tissue perfusion and prevent further complications, such as hypoxia or hypoxic respiratory failure. Administering oxygen via a high flow mask will help increase the oxygen supply and support the client’s breathing until further diagnostic and therapeutic interventions can be made.

Why the other options are incorrect at this time:

Obtain chest x-ray: While a chest x-ray is necessary to confirm the diagnosis (e.g., pneumothorax or another lung injury), the immediate priority is to stabilize the client’s oxygenation. A chest x-ray can be done after initial interventions, but it should not delay oxygenation.

Prepare for chest tube insertion: A chest tube may be necessary if the client is diagnosed with a pneumothorax or hemothorax, but the immediate priority is to stabilize oxygenation. Chest tube insertion can be performed after the client is sufficiently oxygenated or stabilized.

Initiate IV access: While IV access is important for administering fluids, medications, or blood products if needed, it is not the first priority in this situation. The primary concern at this moment is ensuring adequate oxygenation.

Summary:

The nurse should first administer oxygen via high flow mask to stabilize the client’s oxygen levels and manage the respiratory distress. Once the client is oxygenated, further assessments (e.g., chest x-ray) and interventions (e.g., chest tube insertion) can be carried out based on the findings.